Originally developed and empirically supported as an outpatient treatment
for borderline personality disorder (BPD) (Linehan,
1993a, 1993b; Linehan et al., 1991), dialectical
behavior therapy (DBT) recently has been adapted for adults with BPD and comorbid substance use disorders (SUDs)
(Linehan et al., 2002, 1999). This modified
treatment, DBT-SUD, has shown promise in two small randomized controlled trials
and is currently being tested in a two-site study (University of Washington and
Duke University Medical Center) funded by the National Institute of Drug Abuse
(NIDA). The purpose of this paper is to provide a primer on the basics of
DBT-SUD. For more comprehensive descriptions of DBT-SUD, the interested reader
is referred to the treatment manual (Linehan 1993b),
treatment outcome studies (Linehan et al., 2002,
1999), online resources for DBT-SUD training <www.behavioraltech.org> or
book chapters on DBT-SUD (Rosenthal et al., 2005).

Dialectical behavior therapy for adults with BPD and comorbid
SUDs was developed, in part, out of recognition that
individuals with BPD often have problems with substance abuse, and that up to
two-thirds of those diagnosed with SUD also meet diagnostic criteria for BPD (Dulit et al., 1990). In addition, there may be common
etiological and maintaining factors across BPD and SUD, such as difficulties
with the regulation of emotional experience and expression, as well as
impulsivity (Bornovalova et al., 2005; Trull et al., 2001). Clinicians are faced with an enormous
challenge when treating individuals with co-occurring BPD and SUD. Compared to
those with BPD only, those with BPD and SUDs may show
more severe psychopathology, including greater anxiety and suicide attempts
(van den Bosch et al., 2001). It is unclear whether standard drug counseling
approaches common in the substance abuse treatment community (e.g., 12-step)
are efficacious for these difficult-to-treat patients. However, guidelines for
implementing treatments for dually diagnosed patients have been articulated
(Drake et al., 2001), and such treatments have been developed for individuals
with both SUD and schizophrenia, antisocial personality disorder, and a history
of interpersonal victimization, for example (Barrowclough et al., 2001; Drake
et al., 1993; Messina et al., 1999; Najavits et al.,
1998). In line with the hypothesis that a specifically tailored
treatment may be appropriate for this population, and following NIDA guidelines
for psychosocial treatment development, Linehan and
colleagues developed DBT-SUD (unpublished data).

Like standard DBT, the modified version of this outpatient treatment is a
blend of change (e.g., behavior therapy) and acceptance (e.g., mindfulness
training) approaches woven together by a set of philosophical assumptions, a
biosocial theory and multiple modes of treatment (e.g., individual therapy,
group skills training, pharmacotherapy). On the one hand, as a behavioral
treatment, DBT-SUD relentlessly pursues changing a range of maladaptive
behaviors using standard behavioral principles and procedures (e.g.,
contingency management, shaping, stimulus control). On
the other hand, as an acceptance-based treatment, DBT-SUD provides an
unwavering emphasis on patient validation, mindfulness skills, and an
underlying assumption, that, in some moments of life, efforts to change what
inherently cannot be changed may exacerbate problems, rather than solve them.

Instead of monochromatically being change- or acceptance-focused, the DBT-SUD therapist carefully integrates both behavioral change and acceptance throughout all aspects of
treatment. Indeed, the ubiquitous dialectic in DBT is that of acceptance and
change. Neither one alone is thought to be sufficient for all problems.
Instead, the DBT-SUD therapist constantly is searching for ways to help any
given problem using either, or both, change and acceptance strategies. The
pragmatic goal is to identify and implement an optimal solution to each problem
that arises in a fluid context, while being completely willing to let go of any
solution, as needed, in response to new problems or evidence that any one
solution does not appear to be helpful. A balance between acceptance and change
is important, but this does not always translate literally into an equal
distribution of acceptance and change. Like a skilled athlete adjusting to the
weather conditions during a game, the relative proportion of acceptance and
change is a function of what appears useful in any given moment.

Empirical Support

Two randomized trials examining DBT-SUD have been conducted. In the first
study, 28 women diagnosed with BPD and/or SUD were randomly assigned to receive
one year of DBT-SUD or treatment as usual (TAU) in the community (Linehan et al., 1999). After treatment, patients receiving
DBT-SUD attended significantly more individual psychotherapy sessions, dropped
out of treatment less often and had significantly less substance use, as
measured via structured interviews and urinary analyses. At 16-month follow-up,
patients receiving DBT-SUD reported higher global and social adjustment
compared to those receiving TAU.

In the second study, 23 adults with BPD and opioid
dependence (all heroin) were randomly assigned to receive either one year of
DBT-SUD or a comprehensive treatment that included 12-step meetings (e.g.,
Narcotics Anonymous/Alcoholics Anonymous) plus individual therapy sessions
using a manualized approach based purely in
acceptance without direct emphasis on behavioral change (comprehensive
validation therapy) (Linehan et al., 2002). All
patients concurrently received levomethadyl (Orlaam) as an opiate replacement medication. Patients in
both treatment conditions evidenced decreases in drug use and improvements in
social and general adjustment following treatment. However, in the last four
months of treatment, patients receiving DBT-SUD continued to maintain previous
treatment gains, whereas those receiving comprehensive validation had an
increase in opiate use. Although a larger follow-up study currently is being
conducted to replicate and extend these findings, these preliminary studies
taken together suggest that DBT-SUD holds promise as a treatment for substance
users with BPD.